Peritoneal Dialysis

Peritoneal dialysis
Peritoneal dialysis in the treatment of stage 5

chronic kidney disease
Issued: July 2011
NICE clinical guideline 125

www.nice.org.uk/cg125
NHS Evidence has accredited the process used by the Centre for Clinical Practice at NICE to
produce guidelines. Accreditation is valid for 3 years from September 2009 and applies to guidelines
produced since April 2007 using the processes described in NICE's 'The guidelines manual' (2007,
updated 2009). More information on accreditation can be viewed at www.evidence.nhs.uk
Copyright © NICE 2011

Peritoneal dialysis NICE clinical guideline 125
Contents
Introduction .................................................................................................................................. 4
Peritoneal dialysis for patients with chronic kidney disease stage 5 ...................................................... 4
Who this guideline is for .......................................................................................................................... 5
Patient-centred care ..................................................................................................................... 6
1 Guidance ................................................................................................................................... 7
1.1 List of all recommendations ............................................................................................................. 7
2 Notes on the scope of the guidance .......................................................................................... 11
3 Implementation ......................................................................................................................... 12
4 Research recommendations ..................................................................................................... 13
4.1 Process of decision-making .............................................................................................................. 13
4.2 Effectiveness of modality................................................................................................................... 13
4.3 Treatment sequence ......................................................................................................................... 14
4.4 Nutritional status .............................................................................................................................. 14
4.5 Evaluating effectiveness.................................................................................................................... 15
5 Other versions of this guideline ................................................................................................. 16
5.1 Full guideline ..................................................................................................................................... 16
5.2 Quick reference guide ....................................................................................................................... 16
5.3 'Understanding NICE guidance' ........................................................................................................ 16
6 Related NICE guidance ............................................................................................................. 17
Published................................................................................................................................................. 17
7 Updating the guideline............................................................................................................... 18
Appendix A: The Guideline Development Group, the Short Clinical Guidelines Technical Team,
the Short Clinical Guidelines Team and the Centre for Clinical Practice ...................................... 19
Guideline Development Group ................................................................................................................ 19
Short Clinical Guidelines Technical Team ............................................................................................... 20
Short Clinical Guidelines Team ............................................................................................................... 20
Copyright © NICE 2011. All rights reserved. Last modified July 2011 Page 2 of 24
Centre for Clinical Practice...................................................................................................................... 21
Appendix B: The Guideline Review Panel.................................................................................... 22
About this guideline ...................................................................................................................... 23
Introduction
This guidance has been incorporated into the chronic kidney disease NICE Pathway, along
with other related guidance and products.
Peritoneal dialysis for patients with chronic kidney disease

stage 5
At any one time in the UK, 400–800 people per million of the population need renal replacement
in the form of dialysis. The prevalence of dialysis in the UK is highly age dependent – for adults
aged 70–80 years it is between 1600 and 2000 people per million. Dialysis is needed to sustain
life for patients with chronic kidney disease (CKD). For about 40% of adults on dialysis a kidney
transplant is the treatment of choice; this percentage is higher in children. If patients do not have
a kidney transplant, dialysis is needed for the rest of the patient's life.
Two main types of dialysis are available, haemodialysis and peritoneal dialysis. The main factors
that determine what type of dialysis people with chronic kidney disease have are patient
preferences about which treatment fits best within their lifestyle, availability of options within a
service and clinical contraindications. Factors patients and carers may need to consider about
peritoneal dialysis are: the ability to carry out dialysis themselves; the support services they need
to carry out dialysis; integration of dialysis with work, school, hobbies, and social and family
activities; opportunities to maintain social contacts; possible modifications to their home; the
distance and time travelling to hospital; flexibility of daily treatment, diet and medication
regimens; and possible changes to body image and physical activities because of dialysis
access points.
Peritoneal dialysis can be delivered safely and effectively at home or at another location of the
patient's choice. Patients administer it themselves although children, and some adults, might
need help from their families or carers. Patients must have a clean and hygienic place to
exchange dialysis fluid and/or set up dialysis delivery devices either to have dialysis throughout
the day (continuous ambulatory peritoneal dialysis [CAPD]) or overnight while they are asleep
(automated peritoneal dialysis [APD] and assisted automated peritoneal dialysis [aAPD]). A small
room or shed will be needed to store deliveries of dialysis fluid.
The proportion of people with chronic kidney disease (CKD) starting treatment on home- or
hospital-based dialysis, and peritoneal or haemodialysis treatment, varies considerably. The
proportion of people with chronic kidney disease using peritoneal dialysis ranges from 0–30% in
adults, possibly because of variation in local practice and resources, and is as high as 56% in
children.
There is currently no national guidance in England and Wales on supporting people to make
informed decisions about renal replacement therapy, specifically peritoneal dialysis. Nor is there
guidance on the role of aAPD in an integrated dialysis or renal replacement programme or
individual patient pathway.
This short clinical guideline aims to improve the care of people with stage 5 CKD who need and
want to receive dialysis, by making evidence-based recommendations on the role of peritoneal
dialysis.
Who this guideline is for
This document is for healthcare professionals who support people with stage 5 CKD who need
dialysis and other staff who care for people with stage 5 CKD who need renal replacement
therapy (specifically peritoneal dialysis).
Patient-centred care
This guideline offers best practice advice on the care of adults, children and young people with
stage 5 CKD.
Treatment and care should take into account patients' needs and preferences. People with CKD
should have the opportunity to make informed decisions about their care and treatment, in
partnership with their healthcare professionals. If patients do not have the capacity to make
decisions, healthcare professionals should follow the Department of Health's advice on consent
and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare
professionals should follow advice on consent from the Welsh Government.
If the patient is under 16, healthcare professionals should follow the guidelines in the Department
of Health's 'Seeking consent: working with children'.
Good communication between healthcare professionals and patients is essential. It should be

supported by evidence-based written information tailored to the patient's needs. Treatment and
care, and the information patients are given about it, should be culturally appropriate. It should
also be accessible to people with additional needs such as physical, sensory or learning
disabilities, and to people who do not speak or read English.
Families and carers should be given the information and support they need.
Care of young people in transition between paediatric and adult services should be planned and
managed according to the best practice guidance described in 'Transition: getting it right for
young people'.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to
young people with CKD. Diagnosis and management should be reviewed throughout the
transition process, and there should be clarity about who is the lead clinician to ensure continuity
of care.
1 Guidance
The following guidance is based on the best available evidence. The full guideline gives details
of the methods and the evidence used to develop the guidance.
1.1 List of all recommendations
Information and support
1.1.1 Offer patients with stage 5 chronic kidney disease (CKD) and their families and
carers information and support in line with 'Chronic kidney disease' (NICE
clinical guideline 73, 2008).
1.1.2 Offer patients and their families and carers oral and written information about
pre-emptive transplant, dialysis, and conservative care to allow them to make
informed decisions about their treatment.
1.1.3 To enable patients to make informed decisions, offer balanced and accurate
information about all dialysis options. The information should include:
a description of treatment modalities (assisted automated peritoneal dialysis

[aAPD], automated peritoneal dialysis [APD], continuous ambulatory peritoneal
dialysis [CAPD], and home or in-centre haemodialysis) including:
efficacy
risks
potential benefits, based on the person's prognosis
potential side effects and their severity
changing the modality of dialysis and the possible consequences (that is, the
impact on the person's life or how this may affect future treatment or
outcomes)
a discussion about how treatment fits into people's lives, including:
the patient's and/or carer's ability to carry out and adjust the treatment
themselves
integration with daily activities such as work, school, hobbies, family

commitments and travel for work or leisure
opportunities to maintain social interaction
the impact on body image
how the dialysis access point on the body may restrict physical activity
if their home will need to be modified to accommodate treatment
distance and time spent travelling for treatment
flexibility of treatment regimen
any additional support or services that might be needed from others.
1.1.4 Explain to patients and check they understand that CKD is a lifelong disease,
and that during the course of renal replacement therapy they are likely to need
to switch between treatment modalities depending on clinical or personal
circumstances.
1.1.5 When providing information about treatment options, healthcare professionals

should discuss and take into account any information the patient has obtained
from other patients, families and carers and all other sources, and how this
information has influenced their decision.
1.1.6 Make sure that healthcare professionals offering information have specialist
knowledge about CKD and the necessary skills to support decision-making.
This may include training in:
using decision aids to help patients make decisions about their care and treatment
presenting information to children in a form suitable for their developmental stage,

such as play therapies.
1.1.7 Trained healthcare professionals (see recommendation 1.1.6) should be

available to discuss the information provided both before and after the start of
dialysis.
1.1.8 Offer all patients who have presented late, or started dialysis treatment
urgently, an enhanced programme of information, at an appropriate time, that
offers the same information and choices as those who present at an earlier
stage of chronic kidney disease.
Choosing dialysis
1.1.9 Offer all people with stage 5 CKD a choice of peritoneal dialysis or
haemodialysis, if appropriate, but consider peritoneal dialysis as the first
choice of treatment modality for:
children 2 years old or younger
people with residual renal function
adults without significant associated comorbidities.
1.1.10 When discussing choice of treatment modalities, healthcare professionals

should take into account that people's priorities are not necessarily the same
as their own clinical priorities.
1.1.11 Before starting peritoneal dialysis, offer all patients a choice, if appropriate,
between CAPD and APD (or aAPD if necessary).
1.1.12 For children for whom peritoneal dialysis is appropriate, offer APD in
preference to CAPD if they are on a liquid diet, especially if they have low
residual renal function.
Switching treatment modalities
1.1.13 Do not routinely switch patients on peritoneal dialysis to a different treatment

modality in anticipation of potential future complications such as encapsulating
peritoneal sclerosis. However, healthcare professionals should monitor risk
factors such as loss of ultrafiltration and discuss with patients regularly the
efficacy of all aspects of their treatment.
1.1.14 Consider switching treatment modality if the patient, their family or carer asks.
1.1.15 When considering switching treatment modality, offer information on treatment

options described in recommendations 1.1.1–1.1.8. This should also include
how any decision to switch may affect future treatment options.
1.1.16 Switching between treatment modalities should be planned if possible.
2 Notes on the scope of the guidance
NICE guidelines are developed in accordance with a scope that defines what the guideline will
and will not cover. The scope of this guideline is available from our website – click on 'How this
guidance was developed'.
3 Implementation
NICE has developed tools to help organisations implement this guidance.
4 Research recommendations
We have made the following recommendations for research, based on our review of evidence, to
improve NICE guidance and patient care in the future.
4.1 Process of decision-making
How should the process of decision-making about the choice of dialysis modality, including
peritoneal dialysis, be supported?
Why this is important
Various methods are used to support people making healthcare decisions through either formal
or informal systems, but there was no evidence on which method is most effective in the choice
of dialysis modality. Qualitative evidence showed that people were influenced by the experience
of other patients. However, this also has the potential to harm informed decision-making,
because this information is very subjective and can discourage patients from making a decision
informed by their own values.
Further research is needed on how decisions about the modality of dialysis can be supported.
Methods might include how you could use peer support to make decisions based on the patient's
own values, the use of a decision coach and the use of structured information for children.
Research should also evaluate whether these methods vary in effectiveness at different stages
of the pathway or for different decisions (for example, the start of dialysis or the decision to
switch modality or not). The impact of the method or timing of information-giving on clinical
outcomes should be assessed. Other outcomes should include whether the information given
matched the actual experience of the patient after the decision was made.
4.2 Effectiveness of modality
What factors determine the effectiveness of any modality of dialysis, including peritoneal
dialysis?
There are substantial barriers to using randomised controlled trials (RCTs) in research on dialysis
modality. This is a particular challenge for dialysis in children because any UK study is unlikely to
be adequately powered. Also, patient preference is such an important factor in the choice of
modality that when RCTs have been set up recruitment targets have not been met, so results
were uncertain and of limited value.
Qualitative evidence shows that that patients and healthcare professionals perceive many factors
as influencing the effectiveness of dialysis. These include age (specifically age 65 years and
older), level of support and family functioning (relationships, organisation, coping strategies and
life events). However, there is little robust qualitative evidence in this area.
Further research is needed to identify factors that predict treatment success or failure. Outcomes
should include clinical outcomes (including preservation of renal function and rates of infection),
dropout rates, psychosocial factors, quality of life, and adherence.
4.3 Treatment sequence
What is the most effective sequence of treatment?
There is limited high-quality evidence on the effectiveness of different sequencing of modalities,

and specifically on the impact of starting peritoneal dialysis in people with residual renal function.
There is also limited high-quality evidence on when people should be switched to or from
peritoneal dialysis.
Further research is needed on sequencing of treatment, including the optimal time for switching.
4.4 Nutritional status
Is there any significant difference in nutritional status between people on the different dialysis
treatment modalities?
Undernutrition is a frequent finding in people with established renal failure (present in 30–40% of
patients) and is associated with reduced survival. Conversely, weight gain, or regain, is common
after starting peritoneal dialysis and is associated with a worsening lipid profile. Very high and
low serum phosphate concentrations are also associated with poor outcomes.
Clinical interventions are currently used to try to correct both abnormal phosphate levels and
malnutrition.
A rigorous study, using validated methods, is needed to compare the effects of haemodialysis
and peritoneal dialysis on markers of nutritional status and phosphate control.
There is no single gold standard measure of nutritional status, so a panel of measurements

should be used, reflecting the various aspects of protein–energy malnutrition. These outcome
measurements should include subjective global assessment, assessment of dietary intake,
anthropometric measures, weight and body mass index, biochemical markers (including
phosphate, calcium, serum creatinine and albumin), and estimation of dialysis adequacy and
residual renal function.
4.5 Evaluating effectiveness
Which outcomes should be used in evaluating effectiveness?
Studies evaluating the effectiveness of different modalities report many different outcomes.
However, it is not known which is the best measure to compare effectiveness between
treatments.
Further research is needed to determine which outcomes are of most value to patients and
healthcare professionals when deciding on dialysis modality.
5 Other versions of this guideline
5.1 Full guideline
The full guideline, 'Peritoneal dialysis: Peritoneal dialysis in the treatment of stage 5 chronic
kidney disease', contains details of the methods and evidence used to develop the guideline.
5.2 Quick reference guide
A quick reference guide for healthcare professionals is available.
5.3 'Understanding NICE guidance'
A summary for patients and carers ('Understanding NICE guidance') is available.
We encourage NHS and voluntary sector organisations to use text from this booklet in their own
information about stage 5 CKD.
6 Related NICE guidance
Published
Anaemia management in people with chronic kidney disease. NICE clinical guideline 114
(2011).
Chronic kidney disease. NICE clinical guideline 73 (2008)
Laparoscopic insertion of peritoneal dialysis catheter. NICE interventional procedure

guidance 208 (2007).
Guidance on home compared with hospital haemodialysis for patients with end-stage renal
failure. NICE technology appraisal guidance 48 (2002).
7 Updating the guideline
NICE clinical guidelines are updated so that recommendations take into account important new
information. New evidence is checked 3 years after publication, and healthcare professionals
and patients are asked for their views; we use this information to decide whether all or part of a
guideline needs updating. If important new evidence is published at other times, we may decide
to do a more rapid update of some recommendations. Please see our website for information
about updating the guideline.
Appendix A: The Guideline Development Group, the Short

Clinical Guidelines Technical Team, the Short Clinical
Guidelines Team and the Centre for Clinical Practice
Guideline Development Group
Lindsey Barker
Consultant Nephrologist and Medical Director, Royal Berkshire Hospital Foundation Trust,
Reading
Hilary Bekker
Senior Lecturer in Behavioural Sciences, Leeds Institute of Health Sciences, School of Medicine,
University of Leeds,
David Bennett-Jones
Consultant, Renal Medicine, University Hospital Coventry and Warwickshire
Roy Connell
Clinical Nurse Specialist, Nottingham University Hospital
Robert Dunn
Patient and carer member, National Kidney Federation
Helen Hurst
Advanced Nurse Practitioner, Manchester Royal Infirmary
Lesley Lappin
Clinical Nurse Specialist/Community Dialysis Manager, Salford Royal Infirmary, Manchester
Damien Longson – Chair

Consultant Liaison Psychiatrist, Manchester Mental Health and Social Care Trust
Sue Perry
Deputy Head of Dietetic Services, Hull and East Yorkshire Hospitals
Lesley Rees
Consultant Paediatric Nephrologist, Great Ormond St Hospital for Children NHS Trust, London
Amanda Venters
Patient and carer member
Short Clinical Guidelines Technical Team
A short clinical guidelines technical team was responsible for this guideline throughout its
development. It prepared information for the Guideline Development Group, drafted the guideline
and responded to consultation comments. The following NICE employees made up the technical
team for this guideline.
Kathryn Chamberlain
Project Manager
Mendwas Dzingina
Technical Analyst (Health Economics) (from February 2011)
Sarah Glover
Information Specialist
Prashanth Kandaswamy
Technical Adviser (Health Economics)
Beth Shaw
Technical Adviser
Sheryl Warttig
Technical Analyst (from February 2011)
Short Clinical Guidelines Team
Mark Baker
Consultant Clinical Adviser
Nicole Elliott
Associate Director
Michael Heath
Programme Manager
Centre for Clinical Practice
Emma Banks
Guidelines Coordinator
Stefanie Reken
Technical Analyst (Health Economics)
Judith Richardson
Associate Director
Rachel Ryle
Guidelines Commissioning Manager
Judith Thornton
Technical Adviser
Rachael Paterson, Korin Knight-Mossop, Susan Burlace

Editors
Appendix B: The Guideline Review Panel
The Guideline Review Panel is an independent panel that oversees the development of the
guideline and takes responsibility for monitoring adherence to NICE guideline development
processes. In particular, the panel ensures that stakeholder comments have been adequately
considered and responded to. The panel includes members from the following perspectives:
primary care, secondary care, lay, public health and industry.
Dr John Hyslop (Chair)

Consultant Radiologist, Royal Cornwall Hospital NHS Trust
Mrs Sarah Fishburn

Patient and carer member
Mr Kieran Murphy
Health Economics and Reimbursement Manager, Johnson & Johnson Medical Devices &
Diagnostics (UK)
Dr Ash Paul
Deputy Medical Director, Health Commission Wales
Professor Liam Smeeth

Professor of Clinical Epidemiology, London School of Hygiene and Tropical Medicine
About this guideline
NICE clinical guidelines are recommendations about the treatment and care of people with
specific diseases and conditions in the NHS in England and Wales.
The guideline was developed by the Short Clinical Guidelines Technical Team. The teamworked
with a group of healthcare professionals (including consultants, GPs and nurses), patients and
carers, and technical staff, who reviewed the evidence and drafted the recommendations. The
recommendations were finalised after public consultation.
The methods and processes for developing NICE clinical guidelines are described in The
guidelines manual. This guideline was developed using the short clinical guideline process.
The recommendations from this guideline have been incorporated into a NICE Pathway. We
have produced a summary for patients and carers. Tools to help you put the guideline into
practice and information about the evidence it is based on are also available.
Changes since publication
21 December 2011: Copied into NICE guideline template, links checked.
Your responsibility
This guidance represents the view of NICE, which was arrived at after careful consideration of
the evidence available. Healthcare professionals are expected to take it fully into account when
exercising their clinical judgement. However, the guidance does not override the individual
responsibility of healthcare professionals to make decisions appropriate to the circumstances of
the individual patient, in consultation with the patient and/or guardian or carer, and informed by
the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers.

Commissioners and providers are reminded that it is their responsibility to implement the
guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have
regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a
way that would be inconsistent with compliance with those duties.
Copyright
© National Institute for Health and Clinical Excellence 2011. All rights reserved. NICE copyright
material can be downloaded for private research and study, and may be reproduced for
educational and not-for-profit purposes. No reproduction by or for commercial organisations, or
for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
National Institute for Health and Clinical Excellence

Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT
www.nice.org.uk
nice@nice.org.uk
0845 033 7780

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Peritoneal dialysis in the treatment of stage 5

Issued: July 2011

NICE clinical guideline 125

Copyright © NICE 2011

Who this guideline is for .......................................................................................................................... 5

Patient-centred care ..................................................................................................................... 6

1.1 List of all recommendations ............................................................................................................. 7

2 Notes on the scope of the guidance .......................................................................................... 11

4 Research recommendations ..................................................................................................... 13

4.1 Process of decision-making .............................................................................................................. 13

4.2 Effectiveness of modality................................................................................................................... 13

4.3 Treatment sequence ......................................................................................................................... 14

4.4 Nutritional status .............................................................................................................................. 14

4.5 Evaluating effectiveness.................................................................................................................... 15

5 Other versions of this guideline ................................................................................................. 16

5.1 Full guideline ..................................................................................................................................... 16

5.2 Quick reference guide ....................................................................................................................... 16

5.3 'Understanding NICE guidance' ........................................................................................................ 16

6 Related NICE guidance ............................................................................................................. 17

7 Updating the guideline............................................................................................................... 18

Guideline Development Group ................................................................................................................ 19

Short Clinical Guidelines Technical Team ............................................................................................... 20

Short Clinical Guidelines Team ............................................................................................................... 20

Centre for Clinical Practice...................................................................................................................... 21

Appendix B: The Guideline Review Panel.................................................................................... 22

About this guideline ...................................................................................................................... 23

Peritoneal dialysis for patients with chronic kidney disease

Who this guideline is for

Good communication between healthcare professionals and patients is essential. It should be

1.1 List of all recommendations

Information and support

a description of treatment modalities (assisted automated peritoneal dialysis

potential benefits, based on the person's prognosis

potential side effects and their severity

a discussion about how treatment fits into people's lives, including:

integration with daily activities such as work, school, hobbies, family

opportunities to maintain social interaction

the impact on body image

if their home will need to be modified to accommodate treatment

distance and time spent travelling for treatment

flexibility of treatment regimen

any additional support or services that might be needed from others.

1.1.5 When providing information about treatment options, healthcare professionals

presenting information to children in a form suitable for their developmental stage,

1.1.7 Trained healthcare professionals (see recommendation 1.1.6) should be

children 2 years old or younger

people with residual renal function

adults without significant associated comorbidities.

1.1.10 When discussing choice of treatment modalities, healthcare professionals

Switching treatment modalities

1.1.13 Do not routinely switch patients on peritoneal dialysis to a different treatment

1.1.15 When considering switching treatment modality, offer information on treatment

1.1.16 Switching between treatment modalities should be planned if possible.

2 Notes on the scope of the guidance

NICE has developed tools to help organisations implement this guidance.

4.1 Process of decision-making

Why this is important

4.2 Effectiveness of modality

Why this is important

4.3 Treatment sequence

What is the most effective sequence of treatment?

Why this is important